College of Paramedics Research Conference 2024

Head trauma, or suspected head trauma, makes for a large percentage of pre-hospital attendances and subsequent admissions, based on current NICE guidelines, especially where anticoagulant therapy is in use with adult patients. My proposal will lay out the data supporting the need for a PICO comparison study, whereby measurements of a patient’s optic nerve sheath diameter (ONSD) are taken prior to admission and then compared to CT head findings in order to demonstrate that the correlation between ONSD findings can effectively rule out the need for admission for CT head. I would enrol a selected number of pre-hospital advanced clinical practitioners across ambulance service trusts to ensure there is high heterogeneity across similar systems and a variety of patient demographics for all adult patients with known or suspected head trauma and without signs and symptoms that would exclude them from the study. We would either enrol the patient at the time of attendance and gain consent from them or gain access to CT head findings via the pre-existing pre-hospital emergency medicine feedback process in the selected hospital trusts. We would use an agreed point-of-care ultrasonography (POCUS) device across the study group, and run the study for a year before collating data and publishing findings. All enrolled practitioners will undergo comparable training to reduce clinical variance in assessment and interpretation. My hypothesis is that we

• Drone delivery of a defibrillator, lowered by winch to a simulated cardiac arrest.
• A fixed-wing Penguin B drone equipped with satellite-enabled technology successfully conducting end-to-end 'beyond visual line of sight' flight delivery of a defibrillator by parachute drop to a simulated cardiac arrest.• A foundation study for drone-based delivery services to support the Welsh NHS: exploration of a medical drone delivery service between the Welsh Blood Service in South Wales and Wrexham to support and potentially replace current carbon-based transport.

Conclusions:
The Wales Health Drone Research & Innovation Partnership continues to test and develop drone technology, build the body of knowledge, raise public awareness and provide the assurances required for drones to contribute to efficient, effective and sustainable healthcare.

Results:
We recruited 385 participants, predominantly male paramedics (62%), with a median age of 35 and eight years of ambulance service experience.Participants reported frequent encounters with older adults with head injuries and expressed high confidence in assessing visible injuries, but lower confidence in neurological examinations.Participants found NICE and JRCALC guidelines satisfactory and reported confidence in conveying patients to the ED, but less confidence in alternative referrals or discharges.The interviews revealed two over-arching themes: guideline-based care and patient-centred care, with sub-themes emphasising the importance of shared decision-making, collaboration with other healthcare professionals and safety-netting strategies.

Conclusion:
While clinicians express confidence in using clinical guidelines for ED conveyances, they often find guidelines overly prescriptive and struggle to translate them for individual cases.
There is a need for more patient-centred, holistic decision making, especially considering the unique aspects of head injuries in older adults.Challenges include fear of poor outcomes, limited feedback on patient outcomes and lower confidence in making referral or discharge decisions.Specific guidelines tailored to this demographic, as well as improved support services, may aid in reducing unnecessary ED conveyances.
Are paramedics trained to manage maternal cardiac arrest?What can we learn from the experiences of paramedics managing antenatal maternal cardiac arrest in the out-of-hospital environment to guide training?

Charlotte Dennis
Queen Mary University of London Email: cejdennis@gmail.com

Introduction:
There is limited research on out-of-hospital antenatal maternal cardiac arrest.
Research in this field is linked to causation of arrest and maternal survival, with little detail of those providing the resuscitation.This research explores the experiences of paramedics required to manage these cases in the out-of-hospital environment and aims to determine whether paramedics feel they are adequately prepared to manage maternal cardiac arrest.
This study aims to understand whether the experiences that paramedics have in managing antenatal maternal cardiac arrest in the out-of-hospital environment can help guide training.
There are three main objectives: 1. To explore the participants' experiences of attending and managing out-of-hospital antenatal maternal cardiac arrest.2. To explore the decision-making process in the management of antenatal maternal arrest in the out-of-hospital environment.3. To identify areas in which training could be altered to improve future patient care from participants' experiences in managing out-of-hospital antenatal maternal cardiac arrest.
Methods: This is primary research, undertaking and analysing six semi-structured interviews with paramedics who had attended an antenatal maternal cardiac arrest within the previous 24 months.Interviews were transcribed and coded in QSR International NVivo version 12, using an inductive thematic approach for analysis.

Results:
The experiences of paramedics managing antenatal maternal cardiac arrest varied.
Challenges specific to the out-of-hospital environment caused delays in patient care, which resulted in additional stress to clinicians.Participants spoke universally that they felt additional training was required to feel confident in managing the patient group and reported that initial training was inadequate, with reports from advanced paramedics noting that uterine displacement either was not performed or was ineffective due to poor technique.Variation occurred in the decision-making process surrounding the performance of an on-scene resuscitative hysterotomy., 2023).This project aimed to describe patients reported as hanging attended by North East Ambulance Service (NEAS) and evaluate the current situation with reference to previous work in this area (Shaw et al., 2021).

Conclusions
Methods: A service evaluation of hangings attended by NEAS between 1 December 2020 and 29 February 2024 was undertaken.Patients were identified from the routine trauma audit.Data were manually extracted from the source clinical record.
Results: Across 39 months, a total of 2002 completed, threatened or attempted hangings were identified.Children (age <18 years) accounted for 7% (n = 128) of cases in the current evaluation compared to 4% (n = 25) of cases in the previous evaluation.Data on adults is summarised in Table 1.
The number of cases per day has nearly doubled; the reasons for this may include increased frequency of attempts, the ongoing impact of the pandemic, economic challenges and improved case identification.However, the rate of out-of-hospital cardiac arrest (OHCA) per day has barely changed, indicating that attempted and threatened hangings account for most of the increase.The age profile remains similar; however, the proportions of women and children have both increased.Many callers with multiple attendances were identified, perhaps indicating patients struggling to access the help they need elsewhere.

Conclusion:
This is one of the largest UK datasets published on this patient group and, when combined with the preceding data, provides a detailed description of 2606 patients across more than five years in the region, with the highest prevalence in the UK.Despite the number of calls resulting in cardiac arrest not increasing greatly, the impact of frequent exposure to these highly traumatic calls needs further investigation.The subset of patients making repeated calls also needs further investigation.
Mental well-being of first-year undergraduate student paramedics before and after experience of their first ambulance placement: a mixed-methods pilot study

Kate Snowdon
University of Sunderland Abstract Introduction: Emergency ambulance workers are at risk of poor mental well-being, with causes being attributed to shift work, stress and exposure to trauma.Student paramedics in the UK conduct ambulance placement as part of their undergraduate training, which exposes them to the same stresses as emergency ambulance workers.There is further evidence to suggest that student paramedics have additional risk factors for poor mental well-being, such as social isolation and transition to adulthood.Despite these increased risks, there is minimal evidence to explore how mental well-being is affected by ambulance placement.This pilot study aimed to describe and explore the mental well-being of UK student paramedics before and after their first ambulance placement.
Methods: Mixed methods were used to collect quantitative and qualitative data from a cohort of first-year student paramedics (n = 30) at the University of Sunderland (UoS) before and after their first ambulance placement.Pre-and post-placement questionnaires using the Warwick-Edinburgh Mental Wellbeing Score (WEMBS) and open questions were used.Quantitative data was analysed using descriptive and inferential statistics and the qualitative data was analysed using thematic analysis.Ethical approval was gained from UoS (reference: 015015).
Results: Twenty participants were included in the final analysis.During the placement, the participants completed an average of 177.5 hours (SD ±36.5) on ambulance placement, with 75% (15/20) reporting that they had witnessed at least one traumatic event during their placement.Before and after placement WEMBS were summarised.Prior to placement, the group (n = 20) had a pre-placement mean WEMBS of 48.45 (SD ±6.73).Two weeks after placement, the group (n = 20) had a mean WEMBS of 50.55 (SD ±5.9).There was a mild increase of 2.1 in post-placement WEMBS, which was insignificant on statistical testing (p = 0.30).Qualitative thematic analysis identified five themes: positive learning experience; theory-practice gap; student-mentor relationship; student resilience; and career consolidation.

Conclusions:
This pilot mixed-methods study found that participants' mental well-being after exposure to their first ambulance placement did not change significantly.Furthermore, thematic analysis of the qualitative results has shown that placement was an overall positive experience.
The ambulance placement also confirmed their career choice and allowed the crossing of the theory-practice gap.Students did experience traumatic events, and paramedic mentor support was shown to be an important protective factor.The methodology worked well; however, there were limitations in the size of the sample, which did not meet WEBMS recommendations.Further research should use a similar design on a bigger scale that is conducted to track student well-being over the entirety of their educational programme to identify protecting and damaging factors to well-being.
The overall CATNAPS aim is to develop a comprehensive fatigue risk management system (FRMS) for UK NHS ambulance services, which is acceptable, feasible and likely to improve patient outcomes and staff well-being and experience.This is the first study to develop a comprehensive approach to fatigue management in an NHS workforce.
In this particular sub-study, we investigate how frontline staff and patients experience current fatigue actions and explore the potential to improve safety culture and reporting.

Methods:
We recruited 30 frontline ambulance staff members and three ambulance service users from two trusts for a one-to-one semi-structured interview.Staff participants were asked about their experience of fatigue, including their engagement with and/or opinions about our coproduced list of components for fatigue management.Patients were also asked for their views about the same recommended actions.All participants were also asked how, and whether, the recommended actions could be implemented, addressing any potential facilitators and barriers.
Thematic analysis was undertaken on the interview data.All members of the research team, including two members from a patient and public involvement perspective, were involved in the analysis.
Results: Seven themes explain staff and patient perspectives on fatigue management, including the proposed implementation of the recommended components of the FRMS: • Fatigue is not spoken about.
• There is a lack of consistency from management.
• Trusts have implemented limited initiatives to manage fatigue.
• Fatigue management is a matter of personal preference.
• There is impact of, and on, the personal lives of staff to consider.
• Staff and patients have views about potential implementation of proposed fatigue management strategies.• There are concerns that fatigue can impact quality of care.
Conclusions: Staff expressed reluctance to report fatigue because of fear of consequences, while both staff and patients supported formalised and evidence-based implementation of fatigue management actions by ambulance trusts.Current actions are predominantly staff led, so they are highly individualised, including caffeine use, role switching and sleep banking.Successful implementation by trusts of preferred fatigue management actions will require buy-in from front-line staff, managerial support, improved resourcing and increased public awareness on the importance of managing fatigue.These insights are informing development of implementation guidance so ambulance services can tailor the FRMS to their staff and their setting.

An exploration of the experiences of disabled paramedics and student paramedics in their clinical and educational settings Nova Bridge
University of Hertfordshire; College of Paramedics Email: akkikko.jb@gmail.comAbstract Introduction: There are approximately 14.6 million disabled people in the UK, with only 4.4 million disabled people of working age in employment.It is well documented that disabled people are more likely to experience prejudice and less favourable treatment in all aspects of their lives, including employment, than those who are not disabled.Published studies exploring the experiences of any disabled healthcare professional in employment and/or education, including paramedics, are extremely limited.Therefore, it was necessary to conduct this research to explore the experiences of disabled paramedics/student paramedics on how their disability affects their clinical practice, working environment and/or education.
Methods: Five objectives were identified: 1. What are the challenges faced by paramedics/student paramedics in their professional lives? 2. What are the experiences of reasonable adjustments for disabled paramedics/student paramedics? 3. What are the experiences of paramedics/student paramedics of bullying/harassment in the workplace?4. What support are disabled paramedics/student paramedics offered in the workplace for their disability? 5. What recommendations do participants have to improve their professional lives?Thematic analysis was rooted in an interpretive ontological philosophy of an anonymous survey with open and closed questions, Likert scales and binary yes/no questions.Questions explored participants' experiences of being disabled, the culture of work/education, reasonable adjustments, disability-related sickness, visible role models and support networks.

Results:
The themes in the data describe both a passively and actively hostile environment for disabled paramedics and student paramedics, where the participants stated they experience barriers in many aspects of their professional lives, a lack of positive and visible disabled role models and a lack of effective support networks.These systemic barriers and negative attitudes surrounding disability may also be reinforcing self-stigma within some of the participants.Reports of positive experiences are very limited.

Conclusions:
The overall experiences of disabled paramedics and student paramedics are not positive.Additional training, focused on inclusive practices and how to challenge both individual and cultural biases, should be undertaken.Further study should be performed to gather examples of effective practice in reasonable adjustments, as well as inclusive/supportive cultures.live-streaming resulted in footage being obtained.Two were indeterminate due to insufficient data: 2/6 (33%) HEMS stand down was achieved due to live-streaming; there was no evidence of psychological harm from the survey, observations or interviews, but there was insufficient survey data from callers or the comparison site to provide confidence.Results suggest live-streaming is feasible to implement, easy to use, acceptable to both lay callers and dispatchers and may aid dispatch decision making.Limitations included the low recruitment of lay public 999 callers, patients and staff from the comparison site (for staff well-being survey).

Conclusion:
Published findings (Taylor et al., 2024) support the decision to progress to a definitive RCT.Further assessment of unintended consequences, benefits and harms of live-streaming is required.

Steve Trenoweth
Bournemouth University ORCID iD: https://orcid.org/0000-0001-8342-499XAbstract Introduction: Research into the transition experiences of newly qualified paramedics (NQPs) suggests that it can be an emotionally turbulent period (Phillips & Trenoweth, 2023).The social process has been emphasised, where NQPs prioritise fitting in and gaining the acceptance of their colleagues (Devenish et al., 2016).There is evidence that NQPs lack confidence (Health Education England, 2018) and self-efficacy, and that this is a source of anxiety that can cause poor well-being (Phillips & Trenoweth, 2023).This study sought to understand the transition experiences of NQPs in the UK and the effect that these experiences had on their well-being.It presents qualitative findings of a larger study.
Methods: A one-year longitudinal design was used with a social constructionist underpinning.Semi-structured interviews were conducted on a convenience sample of 18 NQPs.Constructivist grounded theory was used to conduct and analyse interviews.Initial coding and focused coding were carried out alongside memoing to construct a theory based on participants' experiences.Relevant ethical approval was granted.

Results:
The first year of employment in the ambulance service was emotionally turbulent for NQPs.The category 'Receiving valued and confirmatory feedback' describes how participants valued clinical feedback from established paramedics.Feedback was often unsolicited and informal.This type of feedback was unlocked and freely offered only when participants had gained membership of the social group.Feedback improved their self-efficacy, as well as further establishing their social cohesion and membership of the established group of paramedics.These factors helped participants to navigate the NQP process.Participants placed less value on formal organisational feedback through the NQP process.For other participants, who did not gain membership of the social group, they did not receive feedback from paramedics and this had a detrimental effect on their self-efficacy and well-being.
These findings support evidence that effective feedback can improve self-efficacy and well-being, and can buffer mental health.Formal feedback mechanisms for paramedics have been found to be lacking, and feedback from colleagues is a source of valued and credible opinion.This study strongly supports emerging evidence that peer-to-peer feedback can support self-efficacy and well-being in paramedics, and this is particularly important for NQPs.
Conclusions: NQPs view informal feedback from paramedics as important and credible.It can improve self-efficacy and well-being.Mechanisms that formalise peer-to-peer feedback may help to make the NQP period less turbulent and improve NQPs' self-efficacy and well-being.

Denis Martin
Teesside University Abstract Introduction: Patients who present to emergency care experiencing back pain have a wider range of underlying causes, including higher rates of serious pathology.Clinical guidelines tend to focus on primary care, citing low rates of serious pathology and advocating conservative management of chronic non-specific back pain.These guidelines appear difficult to apply to emergency care, but little is known about emergency clinicians' experiences of delivering care to this patient group.
The primary aim of this study was to explore the experiences of emergency clinicians in caring for patients experiencing back pain.Objectives of the study were to explore: • The understanding of the term 'back pain'; • Perceptions of whether these patients make up a significant proportion of the clinicians' case load; • The care that clinicians provide and their confidence in offering that care; • Opinions of what, if anything, would improve care for this patient group.

Methods:
The study is a qualitative exploration using reflexive thematic analysis to construct themes from a series of semi-structured interviews.The interviewer, and primary coder, is an experienced academic paramedic with an insider position in relation to emergency care.Other members of the research team provided oversight and review.
Results: Thirteen interviews were conducted with a range of emergency clinicians (doctors, paramedics, nurses and physiotherapists).Four themes and ten sub-themes were constructed.The four themes were: understanding back pain; emergency medical services as a legitimate choice for patients; benign or sinister pain; and treatment options.
Conclusions: Emergency clinicians have a nuanced understanding of back pain and its presentations.Their understanding of back pain recognised it as a complex presentation, but their focus is on identifying serious causes.Participants identified limited formal education on back pain and this gap was plugged by their own and others' experiences, often through stories of notable episodes.Clinicians were sympathetic to patients experiencing back pain.Patients were perceived as accessing emergency care due to being distressed; clinicians valued the opportunity to take time with patients, but viewed themselves as the 'back-stop' in healthcare.When differentiating between benign and sinister presentations it was recognised that serious pathologies, while less common, did present to emergency care, and once red flags had been used to rule in or out serious pathology, other cases could be referred elsewhere.While participants felt supported in offering treatment, many of the treatments used are not advocated in national guidelines.

Table 1 .
Summary data on adults identified as hanging compared with previous evaluation.